4875 Pilot Knob Rd - Septic Maintenance Form 2016-06-23 2010-03-27 00:24 >> 6516755694 P 2/3
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For Office Use
I I
� Dale Received: �
City of Ea aIl ; StafE A
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3830 Pilot Knob Road
Eagan MN 55122
Phone; (651)675-5675
Fax;(651)675-5694
Email-, commdeveloumentacitvofeaaan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 7 3 A #of Tanks Pumped: Total Gallons Pumped: VUU
Site Address: (j 7 P l lO F K,J U b
Owner's Name: Q-0/P/?- J C O A-9 f"u J'
Dwner's Address(If different from site):
Maintainer's Name: 3'a6r' s t,L c; ,r-�E, License Number: L
Private Residence: V Commercial: Disposal Location: 7 �C
Condition of Baffles: 6tk�� Type of Tanks: —�40t f L Size of Tanks:
Pumped Through: Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mall,fax or email.